IN ALABAMAadph.org/ADMINISTRATION/chronicdisease.pdf · 2004-05-25 · In addition, one in 20...

IN ALABAMA

Past, Present, and Future Trends

CHRONIC DISEASE IN ALABAMATable of Contents

FOREWORD __________________________ 2

INTRODUCTION _______________________ 3

CURRENT STATUS:

The Prevalence of Chronic Diseasein Alabama ________________________ 4

The Incidence of Cancerin Alabama ________________________ 6

Mortality Associated withChronic Disease in Alabama ____________ 7

Risk Behaviors Reported byAlabama Adults_____________________ 9

Early Detection and Other ProtectiveActivities Reported by Alabama Adults ____ 11

ALABAMA RISK:

Trends in Chronic Disease and AssociatedRisk Factors among Alabama Adults ______ 12

HIGH BURDEN AREASOF THE STATE OF ALABAMA:

A Multifactorial Computation ___________ 14

TABLE 1:

Overall Chronic Disease BurdenRanking by Rank ____________________ 15

TABLE 2:

Overall Chronic Disease BurdenRanking by County __________________ 16

APPENDIX

Definitionsand Methods _______________________ 18

Chronic diseases constitute a major publichealth problem in Alabama. According to theCenters for Disease Control andPrevention(CDC), the combination of a popula-tion that is aging along with unhealthy lifestylechoices will result in an epidemic of chronicdisease that, "...will radically change the qualityof life of our citizens and potentially bankruptthe health care system." Some of the chronicdiseases mentioned by CDC include cancer,arthritis, diabetes, stroke, and heart disease. Byadopting healthier lifestyles and managingexisting conditions better, it is possible toimprove the overall health of Alabama’s citi-zens. It is critically important that we not onlyrecognize that improvement in Alabama’shealth are necessary to avoid a potentially largeburden of illness, but, in addition, without thisimprovement, the health care system will beseverely strained and health care expenditureswill increase.

This document, "Chronic Disease in Alabama,Past, Present, and Future Trends", presents forthe first time a county by county picture of theestimated burden of important chronic diseasesand risk factors. These include: adult smoking,diabetes, hypertension, obesity, coronary heartdisease, lung cancer, breast cancer, and colorec-tal cancer. Counties are ranked from highest tolowest disease burden. Trends from 1990 to2002 are shown for adult smoking, fruit andvegetable intake, obesity, hypertension, and dia-

betes, all of which have progressively worsenedover time. This report also projects selectedrisk factor and chronic disease trends from2002 to 2020, for smoking, diabetes, obesity,hypertension, and arthritis. These trends andprojection have major implications for the pub-lic’s health in relation to life and health careexpenditures. It is evident that, unattended,these projected increases will be substantial andexpensive.

Vigorous efforts to improve the health ofAlabamians must be made. These efforts mustbe a priority for individuals, families, and com-munities in order to minimize the burden ofchronic disease. Reducing the risk of diseaseand minimizing disability from these chronicdiseases will require an investment of resourcesas well as a personal commitment to healthierbehaviors.

Donald E. Williamson, M.D.State Health Officer

FOREWORD:

May, 2004

2

n the 20th century, most publichealth efforts were directed towardthe identification and control ofthreats posed by infectious agents.During that period, infectious dis-eases caused many more deaths andmore morbidity than did chronic,non-infectious diseases. However, inthe latter half of the century andcontinuing into the current century,chronic diseases are the leadingcauses of mortality and morbidity inthe United States. Advances in out-break surveillance and disease treat-ment have led to a dramatic declinein the mortality associated with dis-eases such as influenza, pneumonia,

gastritis and diarrhea, and the like. Heart dis-ease and cancer currently account for manymore deaths than influenza, pneumonia, andAIDS combined, and are the leading causes ofdeath for both men and women within all racialand ethnic groups.

The pattern of mortality in Alabama is

similar to that seen in the nation overall. In theyear 2002, the leading causes of death inAlabama were heart disease and cancer (seeFigure 1). Seven of the nine leading causes ofdeath were chronic, non-infectious conditions.Chronic diseases also account for large portionsof the direct and indirect costs of health care,including inpatient and outpatient medical care,home health care, pharmaceuticals, lost produc-tivity, and lost years of productive life. Chronicdiseases, thus, are an important component ofthe disease burden within the state and animportant component of public health activitiesin Alabama.

This report will provide information aboutthe current prevalence of and mortality associ-ated with key chronic diseases within the state,using the most current and reliable informationavailable. Additionally, information concerningthe proportion of Alabama residents engagingin risk or health-promotion behaviors will bepresented, along with historical trends and pro-jections of future burdens that may be facedwithin the state.

FIGURE 1LEADING CAUSES OF DEATH IN ALABAMA, 2002

Heart diseaseCancerStroke

Unintentional injuriesChronic lung disease

DiabetesPneumonia/Influenza

Kidney diseaseAlzheimer’s

Other

0 5,000 10,000 15,000Deaths

Total deaths =46,017

3

13,1839,685

3,2032,3072,328

1,4851,217

1,0351,189

10,385

CURRENT STATUS:The Prevalence of Chronic Diseasein Alabama

Information about the proportion ofAlabama residents who deal with variouschronic disease conditions is limited. The bestsource of that information is the BehavioralRisk Factor Surveillance Survey (BRFSS), atelephone survey administered annually withinthe state. The estimates of disease occurrenceobtained from the BRFSS are based on self-report and are not confirmed with laboratory orother diagnostic testing.

In 2001-2002, the BRFSS indicated that themost common chronic condition faced byAlabama adults is arthritis, with 36 percent ofrespondents indicating that they had been toldby a physician that they had arthritis (seeFigure 2). Approximately a third (32%) ofAlabama adults had been told that they hadhigh blood pressure, and nearly 9% of Alabamaadults had been told that they had diabetes.Also 11% had been told that they had asthma.

In addition, one in 20 adults (5%) reportedthat they had had a heart attack, 3 percent thatthey had had a stroke, and seven percent overallreported that they had been told they had car-diovascular disease (i.e., angina or heartdisease).

A review of selected conditions for whichdata are available throughout the decade 1990through 2002 indicates that proportion ofAlabama adults who are affected by these con-ditions is increasing in Alabama. For example,the prevalence of self-reported hypertension, asdepicted in Figure 3, has increased from 23percent to 32 percent in 2001, a growth ofsome 38 percent. More dramatically, the preva-lence of self-reported diabetes in the state hasincreased by 50 percent over the decade, from

4

FIGURE 2PREVALENCE OF CHRONIC DISEASE CONDITIONS,

ALABAMA, 2001 - 2002

ArthritisHypertension

AsthmaDiabetes

Cardiovascular diseaseHeart Attack

Stroke

35.8%32%

11%8.5%

7%5%

3%

Source: BRFSS 2001,2002

FIGURE 3TRENDS IN PREVALENCE OF HYPERTENSION

AMONG ALABAMA ADULTS, 1990-200135302520151050

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

Source: BRFSS

FIGURE 4TRENDS IN PREVALENCE OF DIABETES,

ALABAMA ADULTS, 1990-2002121086420

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2001

Source: BRFSS

2002

just under 6 percent in 1990 to nearly 9 percentin 2002 (see Figure 4). While data from theBRFSS are not available to document trends inother conditions (for example, cardiovasculardisease and asthma), data from national surveyssuch as the National Health Interview Surveyand the National Health and NutritionExamination Survey suggest increasing nationaltrends in these conditions also.

For many of the chronic conditions thataffect Alabama adults, the burden of disease isnot equally distributed across racial and ethnicgroups. For example, arthritis is more common

among whites (see Figure 5) than blacks, whilehypertension and diabetes are much more com-mon among blacks. Interestingly, althoughhypertension is more common among blacks,approximately the same proportions of blacksand whites reported having had a stroke, andmore whites than blacks reported having car-diovascular disease and/or a heart attack.

FIGURE 5PREVALENCE OF CHRONIC DISEASE CONDITIONS, BY RACIAL/ETHNIC GROUP ALABAMA, 2002

Arthritis

Hypertension

Asthma

Diabetes

Cardiovascular disease

Heart attack

Stroke

Source: BRFSS 2001, 2002

5

33.3%36.9%

37.4%29.8%

10.9%10.7%

12.8%7.2%

3.2%6.2%

3.7%4.9%

3.5%3.2%

Black White

CURRENT STATUS:The Incidence of Cancerin Alabama

Alabama’s cancer registry tracks the occur-rence of new cancer cases among the state’sresidents. The registry receives informationfrom physicians, laboratories, and hospitalsacross the state. Overall, in the years 1996through 2002 combined, the registry recordedjust over 137,263 new cases of cancer, or anaverage of approximately 19,500 cases peryear. The most frequent forms of cancer werebreast and lung cancer, each accounting formore than 23,000 (16%) of new cancer cases inthe period (see Figure 6). Also during the peri-od, approximately 17,000 cases of prostate can-cer and another 16,000 cases of cancer of thecolon and rectum occurred. Together, these fourcommon forms of cancer accounted for 6 ofevery 10 new cancer cases occurring in theperiod.

Figure 7 depicts the occurrence of new can-cer cases in the period 1996-2002, taking intoconsideration differences in the populationsaffected. Overall, the incidence rate (over thefour years combined) for all forms of cancer isestimated to be 440 cases per 100,000 persons.Breast (135 cases per 100,000 women) andprostate cancers (127 cases per 100,000 men)were the most frequently occurring cancersduring the period. In comparison, the rate oflung cancer was 73 cases per 100,000 personsand the rate of colorectal cancer was 52 casesper 100,000 persons.

57,716

23,108

23,124

16,233

17,082

FIGURE 6INCIDENCE OF CANCER BY TYPE,

IN ALABAMA 1996 - 2002

Source: AL Cancer Report 2002 (AL Cancer Registry)

Total New Cases = 137,263

Prostate (12%)

Colorectal (12%)

Lung (17%)

Breast (17%)

Other (42%)

FIGURE 7INCIDENCE RATES OF CANCER AMONG

ALABAMA RESIDENTS, 1996-2002

Source: AL Cancer Report 2002 (AL Cancer Registry); all rates age-adjusted to 2000 standard million; all rates per 100,000 persons

450

400

350

300

250

200

150

100

50

0All sites Breast Prostate Lung Colorectal Cervical

440

135.5 126.9

7352

10.9

6

Rate

s pe

r 100

,000

per

sons

In 2002, more than 46,000 persons died inAlabama. The 2002 mortality rate was 1,026deaths per 100,000 persons, substantially higherthan the national rate of 849 persons per100,000 population (taking into considerationage differences between the Alabama andnational populations; see Figure 8). Deathsfrom chronic disease conditions accounted for asubstantial portion of this mortality burden inAlabama. The leading cause of mortality, bothin Alabama and in the United States overall,was heart disease, followed by cancer.

As noted in Figure 9, the 2002 mortalityrates for cardiovascular disease (heart attacksand stroke), chronic lower respiratory diseases,diabetes, and hypertensive diseases were higherin Alabama than in the United States. Similarly,Figure 10 indicates that the 2002 cancer mortal-ity rate (all sites combined) for Alabama (209.1deaths per 1000,000 persons) was higher than

the national rate of 194 deaths per 100,000persons.

Lung cancer evidenced a 2002 mortalityrate of 65 deaths per 100,000 persons. This ratewas higher than that observed in the US popu-lation overall (see Figure 11). In comparison, in2002 colorectal cancers accounted for nearly 20deaths per 100,000 persons in the population,and breast and prostate cancer had rates of 15and 13 deaths (respectively) per 100,000 per-sons, all of which were essentially comparableto national rates.

Racial disparities are noted in mortality aswell as in prevalence of disease. In 2002 mor-tality rates associated with stroke, diabetes, andhypertensive disease were higher among blacksthan whites (see Figure 12), while rates of mor-tality associated with chronic lower respiratorydiseases were higher among whites. Mortalityrates associated with heart attack were essen-

CURRENT STATUS:Mortality Associated withChronic Diseases in Alabama

FIGURE 8ALL-CAUSE MORTALITY RATES,

ALABAMA AND UNITED STATES, 2002

1,400

1,200

1,000

800

600

400

200

0

Alabama1,025.7 US

848.9

Source: CDC; all rates age-adjusted to 2000 standard million; all rates per 100,000 persons

All cause

Rate

s pe

r 100

,000

per

sons

7

FIGURE 9MORTALITY RATES,


90

80

70

60

50

40

30

20

10

0Heart attack Stroke Respiratory Diabetes Hypertensive

disease

74.2

62.270.7

56.350.8

43.7

32.325.4

17.416.9

Rate

s pe

r 100

,000

per

sons


Alabama

US

tially comparable for the two groups. Mortalityrates associated with breast, cervical, prostate,and colorectal cancer in 2002 were higheramong blacks than whites (see Figure 13),

while 2002 mortality rates associated with lungcancer were not substantially different betweenthe two groups.

Mortality Associated with Chronic Diseases in Alabama continued

8

FIGURE 10CANCER MORTALITY RATES, ALL SITES COMBINED,


300

250

200

150

100

50

0

Alabama209.1

US194


Cancer – all sites

Rate

s pe

r 100

,000

per

-

FIGURE 11SITE-SPECIFIC CANCER MORTALITY RATES,


70605040302010

0Lung Colorectal Breast Prostate Cervical

65.2

55.1

19.715 14.5 12.510.6

1.7 1.4Rate

s pe

r 100

,000

per

sons


Alabama

US

19.2

FIGURE 12MORTALITY RATES BY RACIAL/ETHNIC GROUP,

ALABAMA 2002

1009080706050403020100

Heart attack Stroke Respiratory Diabetes Hypertensivedisease

89.4

68.4

28.1

56.560.6

24.9

41.0

12.8

Rate

s pe

r 100

,000

per

sons


Black

White90.5

79

FIGURE 13CANCER MORTALITY RATES, BY

RACIAL/ETHNIC GROUP, ALABAMA, 2002

70605040302010

0Lung Breast Cervical Prostate Colorectal

64.4

14.4

3.31.2

22.8

9.8

25.7

17

Rate

s pe

r 100

,000

per

sons


Black

White

16.5

62

A number of factors contribute to the develop-ment of chronic diseases. Some of these factors –such as age, gender, race or ethnic origin, familyhistory, genetic predisposition, and others – cannotbe changed. Some factors associated with diseasedevelopment and severity, however, are modifiable.It is those modifiable risk factors that are the focusof many public health prevention and controlefforts.

The Behavioral Risk Factor SurveillanceSurvey (BRFSS) provides information each yearabout the status of Alabama adults in terms ofthose modifiable risk factors. The most recentinformation available from this survey (see Figure14) indicates that more than three- quarters of thestate’s adults reported that they do not consume therecommended five servings of fruits and/or vegeta-bles daily, and nearly a third (27%) reported thatthey were physically inactive in their daily lives.Given these findings, it is not surprising that amajority (63%) of Alabama’s adults may be at riskfor chronic disease conditions because they areoverweight or obese (based on their self-reportedweight and height).

Further, the survey indicated that in 2002, oneout of every four Alabama adults (24%) was a cur-rent smoker. Given that cigarette use, particularlysmoking, is thought to be associated with a largenumber of chronic conditions — including but notlimited to heart disease, chronic respiratory condi-tions such as asthma and emphysema, and lungcancer – there is reason for concern in these find-ings. Similarly, approximately a third of Alabamaadults indicated that they had been told they hadhigh blood cholesterol, a major risk factor for car-diovascular disease.

The observed trends in these risk factors do notencourage optimism for the future. In Figures 15through 18, the trends in risk factors reported

through the Alabama BRFSS over the decade 1990through 2000 are compared to the trends seennationally for smoking among adults, insufficientfruit and vegetable intake, and physical inactivity.In each case the trends have been unfavorable overthe period.

Although Alabama began the decade with aslightly lower proportion of adult smokers thanwas seen nationally (22% compared to 23%; seeFigure 15), in the latter half of the decade,Alabama’s smoking prevalence has risen and isnow above the national prevalence (25% comparedto 23% nationally). Overall, the proportion ofAlabama smokers has risen 12 percent over thedecade. Since its lowest point in the decade (19%in 1993), the percentage of smokers amongAlabama’s adults has risen 35 percent to thedecade’s high of 25 percent in 2000. In compari-son, the national proportion stayed essentially sta-ble, increasing by less than one percent over thefull 10-year period.

A somewhat different but no less concerningpicture is seen in physical activity levels reportedby Alabama adults within the annual BRFSS (seeFigure 16). In each year of the past decade,Alabama adults reported activity levels that werelower than those reported nationally.

CURRENT STATUS:Risk Behaviors Reported byAlabama Adults

9

FIGURE 14RISK FACTORS AMONG ALABAMA ADULTS

100%80%60%40%20%0%

Insufficientweightcontrol

Insufficientfruit/veg.

intake

Smoking Physical inactivity

Highcholesterol


62.7%78.9%

24.4% 27.3%32.9%

Obese

Overwt.

Risk Behaviors Reported by Alabama Adults continued

Data are not available during the early years ofthe decade to compare fruit and vegetable intakeamong adults in the United States and Alabama(see Figure 17). In 1994, the proportion of adultsnot complying with nutritional guidelines wasslightly higher among Alabama adults, comparedto the proportion seen in the nation overall. In sub-sequent years, the proportion trended downward inAlabama, although the changes were small overalland from year to year. At the end of the period,approximately three-fourths of adults in Alabamaand the nation overall reported that they ate fewerthan the recommended five servings daily.

Taking into account the low levels of physicalactivity and insufficient fruit and vegetable intakereported by adults, it is not surprising that the pro-portion of adults who do not maintain a healthyweight has been increasing substantially nationallyand in Alabama over the past decade (see Figure18). In 1990 the proportions of adults who wereobese were equal in Alabama and the nation over-all (12%). However, over the ensuing decade, theproportion of adults who were obese doubled inAlabama, while the proportion of obese adultincreased nationally at a relatively slower rate. Atthe end of the decade, then, the proportion ofobese adults in Alabama was 16 percent greaterthan that seen in the United States overall.

As depicted in Figure 19, higher proportionsof blacks were obese, physically inactive, and hadhigh cholesterol, compared to their white counter-parts. In contrast, more whites than blacks werecurrent smokers and were overweight (but not yetobese). These disparities between groups likelyexplain some portion of the disparities seenbetween groups in the prevalence of diabetes,which is substantially higher among Alabama’sblack citizens.

10

FIGURE 15TRENDS IN ADULT SMOKING, ALABAMA VERSUS US,

1990-200230%25%20%15%10%

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

FIGURE 16TRENDS IN PHYSICAL INACTIVITY, ALABAMA VERSUS US, 1990-2002

45%40%35%30%25%

FIGURE 17TRENDS IN INSUFFICIENT FRUIT AND VEGETABLE

INTAKE, ALABAMA VERSUS US, 1990-200290%80%70%60%50%

FIGURE 18TRENDS IN OBESITY, ALABAMA VERSUS US,

1990-200230%25%20%15%10%

Figures 15-18, Source: BRFSS

Data not availableprior to 1994.

FIGURE 19RISK FACTORS BY RACE,

ALABAMA, 2002

40%35%30%25%20%15%10%5%0%

Obesity Overweight Smoking Physicalinactivity

Highcholesterol

22.9

37.9

21.524.0

37.4

24.6

34.7

27.5

Source: BRFSS 2001 - 2002 Black

32.835.9

AlabamaUS

AlabamaUS

AlabamaUS

AlabamaUS

White

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

Given the prevalence of chronic disease inAlabama and the mortality rates associated withthose conditions, it is important to look at some ofthe strategies that can be employed individuallyand at the population level to help reduce the bur-den of disease in the state.

The most recent reports from Alabama womenindicated that the majority (66.6%) had undergonea mammogram (see Figure 20). A substantial per-centage (88.4%) had received a clinical breastexam, and a similar number (83.4%) had under-gone screening for cervical cancer within the past 2years. Men were also receiving important screeningtests. A majority (63%) of Alabama men 40 yearsof age or older reported having a PSA test, andthree-fourths of the adult male respondents to theBRFSS reported having had a digital rectal exam.

Further, nearly three of every four Alabamaadults reported having had their blood cholesterollevels checked (see Figure 21). However, manyfewer had been screened for cancer of the colon orrectum. Less than half of Alabama adults reportedthat they had undergone a flexible sigmoidoscopyor a colonoscopy and only 25 percent indicated thatthey had completed a non-invasive fecal occultblood test. Vaccination for common respiratory ill-nesses like influenza and pneumonia can be animportant factor in reducing mortality from theseillnesses, particularly among persons at high risk,such as the elderly. Results from recent administra-tions of the BRFSS indicated that only approxi-mately a third (30%) of Alabama adults hadreceived a flu vaccination, and approximately 21%had received a pneumococcal vaccination (seeFigure 22). Among respondents aged 65 and older,however, the proportions were higher, with 65 per-cent having received a flu vaccination and 59 per-cent having had a pneumococcal vaccination. Inthat high risk group, the proportion of blacks whoreported having had the appropriate vaccinationswas significantly lower than the proportion ofwhites who so reported.

CURRENT STATUS:Early Detection and Other ProspectiveActivities Reported by Alabama Adults

11

FIGURE 20GENDER-SPECIFIC EARLY DETECTION BEHAVIORS

REPORTED BY ALABAMA ADULTS

100%

80%

60%

40%

20%

0%Mammograms Clinical breast

examPap test within

24 monthsPSA test Digital Rectal

exam

83.6

Source: BRFSS 2002

Black

89.684.8 87.491.788.4

81.389.9

83.4

63.861.663.5

79.8

66.0

76.5

WhiteOverall

Women Men

FIGURE 21EARLY DETECTION PROCEDURESREPORTED BY ALABAMA ADULTS

80%

60%

40%

20%

0%Cholesterol check Fecal Occult

Blood test(past two years)

Sigmoid/Colonoscopy


Black73.468.4

75.4

24.5 25.3 24.8

48.744.2

49.4

WhiteOverall

FIGURE 22FLU AND PNEUMOCOCCAL VACCINATIONS,

REPORTED BY ALABAMA ADULTS, 2002

80%

60%

40%

20%

0%Flu Pneumonia Flu Pneumonia

Source: BRFSS 2002

Black

58.4

37.3

63.264.7

52.8

68.3

20.529.8

WhiteOverall

All adults Adults 65 and older

(40 and older)

(All adults 50 and older)

The data presented above indicate thatAlabama faces serious health challenges at thecurrent time. The state ranks above the nationalmedian in percentages of persons who smoke,are obese, are hypertensive, have coronaryheart disease, and have diabetes. Further, thepercentages of persons who are obese or havebeen told that they have diabetes are increasingat alarming rates within the state, proportionsof persons being told they have high bloodpressure are growing larger, and smoking ratesare not diminishing significantly.

To estimate the potential burden that thestate could face in the future if trends in chron-ic disease and risk behaviors continue, thenumbers of persons estimated to suffer fromkey chronic diseases (arthritis, hypertension,diabetes) in the year 2020 were calculated,using population projections from the USCensus Bureau and current prevalence esti-mates from the BRFSS (see appendix fordetails of calculation methods). Similarly, thenumbers of persons estimated to be currentsmokers or to be obese in the year 2020 werecalculated. The assumption underlying thesecalculations was that the rate of disease wouldremain constant at current levels throughoutthe 20-year period to come.

ALABAMA AT RISK:Trends in Chronic Disease and AssociatedRisk Factors among Alabama Adults

12

Results indicate that by the year 2020, Alabama will have an estimated■ 942,531 adults who smoke – an increase of 14 percent■ 982,652 adults who are obese – an increase of 21 percent■ more than 1.4 million adults who are hypertensive – an increase of 30 percent■ 380,828 adults with diabetes – an increase of 40 percent■ more than 1.3 million adults with arthritis – an increase of 30 percent

FIGURE 23ESTIMATED NUMBER OF ALABAMA ADULTS WITH

HYPERTENSION, PROJECTED, 2002-2020*

1,400,0001,200,0001,000,000

800,000600,000400,000200,000

02002 2005 2010 2015 2020

1,075,196

1,402,432+ 327,236 persons

* Assuming stable prevalence in future years Source: US Census Data, BRFSS 1998-2001


ARTHRITIS, PROJECTED, 2002-2020*

1,400,0001,200,0001,000,000

800,000600,000400,000200,000

02002 2005 2010 2015 2020

1,002,204

1,307,597+ 305,393 persons


Purely because of anticipated changes inthe demographic make-up of the state’s popula-tion, and assuming that the trend towardincreasing prevalence of disease is stabilized atthe current level, the number of persons affect-ed by these conditions or engaging in thesebehaviors is estimated to increase by between14 percent (smoking) to 40 percent (diabetes;see Figures 23 through 27).

The assumptions underlying these estimatesare conservative, given the past decade’s histo-ry of increasing prevalence of most chronic dis-eases and risk behavior. It is likely that theincreases depicted on these graphs may, in fact,be greater than shown, if the prevalence of dis-ease continues to increase as history suggests islikely without concentrated interventions.Given the significant costs of treatment for thediseases themselves, the associated complica-tions, and reduced quality of life – for example,stroke, lower extremity amputations, blindness,mobility impairments, and the like – anyincrease in the numbers of persons affected bythese and other serious chronic diseases willmean increased disease burden to be borne byindividuals and the state in the years to come.If this burden is to be abated, emphasis must beplaced on prevention of disease occurrence,early detection of disease, and good diseasemanagement to prevent or delay the onset ofconsequential conditions.

Trends in Chronic Disease and Associated Risk Factors among Alabama Adults continued

13


DIABETES, PROJECTED, 2002-2020*

400,000

300,000

200,000

100,000

02002 2005 2010 2015 2020

272,841

380,828+ 107,987 persons


FIGURE 26ESTIMATED NUMBER OF ALABAMA ADULTS

WHO SMOKE, PROJECTED, 2002-2020*

960,000940,000920,000900,000880,000860,000840,000820,000

2002 2005 2010 2015 2020

828,630

942,532

+ 113,902 persons


FIGURE 27ESTIMATED NUMBER OF OBESE ALABAMA ADULTS,

PROJECTED, 2002-2020*

1,000,000

950,000

900,000

850,000

800,000

750,0002002 2005 2010 2015 2020

810,539

982,652

+ 172,113 persons


For each of several chronic disease condi-tions and common risk factors, county-levelestimates of disease prevalence have been cal-culated. These calcula-tions provide importantprogram-specific informa-tion about the likely pat-tern of disease across thestate. However, chronicdiseases share risk factors(e.g., tobacco use, physi-cal inactivity, obesity) andfrequently occur togetherin the same populations –that is, groups that arelikely to have more heartdisease are also likely tohave more diabetes. It islikely, then, that somecounties have greater bur-dens of chronic diseaseoverall than other coun-ties, based on patterns ofpopulation characteristics,risk factor prevalence,disease occurrence, andaccess to health care.

To estimate thiscombined burden, a multi-factor index was created including: estimatedprevalence of diabetes, coronary heart disease,hypertension, smoking, obesity; incidence oflung cancer, breast cancer, and colorectal can-cer; proportion of the population living inpoverty; and primary care physicians in practicein the county. To overcome the problems inher-ent in combining variables scored on differentscales (for example, proportions compared torates per 100,000), each variable was

standardized to a common scale. The standard-ized scores were then summed and averaged tocreate a single measure of disease burden, the

Burden Score. Based onthese scores, then, coun-ties can be ranked fromhighest to lowest estimat-ed burden. Additionaldetails about the sourcesof data and methodolo-gies used to calculateestimates and create theindex score are presentedin the appendix to thisreport.

The overall rank-ing of counties in termsof their estimated chronicdisease burden is present-ed in Tables 1 and 2 andgraphically depicted inFigure 28. As can beseen, a majority, thoughnot all, of the countiesestimated to face thegreatest burden of chron-ic disease are found inthe black belt region ofthe state, a region that

also includes higher proportions of minorityresidents and persons living in poverty. Giventhat minority populations have been shown tobe at greater risk of having diabetes, hyperten-sion, coronary heart disease, and obesity, it isnot surprising that these counties would beranked higher in terms of overall chronic dis-ease burden. Off-setting that burden, at least tosome extent, may be lower prevalence of smok-ing in minority populations.

HIGH BURDEN AREASOF THE STATE OF ALABAMA:A Multifactorial Computation

14

LAUDERDALE

LIMESTONEMADISON

JACKSON

DEKALBMARSHALL

LAWRENCE

JEFFERSON

CULLMANWINSTONMARION

LAMAR

PICKENS

FAYETTEWALKER

BLOUNT

MACON

LEE

RANDOLPH

CALHOUN

TALLADEGA

DALLAS

CHILTONCOOSA

SHELBYTUSCALOOSA

ST. CLAIR

TALLAPOOSA

CHEROKEE

WILCOX

ELMOREAUTAUGA

ESCAMBIACOVINGTON

BUTLER

MONTGOMERY

BULLOCK

CRENSHAW

GENEVA HOUSTON

DALE

MONROE

GREENE

MARENGO

CHOCTAW

WASHINGTON

MOBILE

BALDWIN

SUMTER

HALE

LOWNDES

BIBB

COFFEE

PIKE

PERRY

CLAY

RUSSELL

BARBOUR

CONECUH

CLARKE

CHAMBERS

CLEBURNE

ETOWAH

FRANKLIN

COLBERT

MORGAN

HENRY

FIGURE 28ALABAMA COUNTIES WITH HIGHEST ESTIMATED

BURDEN OF CHRONIC DISEASE

Gold = rank 18-34 (above statemedian)

Black = rank 1-17 (top 25 percent)

White = rank greater than 34 (lowest estimated burden)

1 .........................................................Hale 2.......................................................Dallas 3 ......................................................Clarke 4 .....................................................Greene 5 .....................................................Mobile 6...................................................Conecuh 7 ..................................................Jefferson 7 .....................................................Wilcox 9 ........................................................Perry 10 ..........................................Montgomery 11 ...............................................Escambia 12 .......................................................Bibb 13....................................................Macon 14 ..................................................Bullock 15 ...............................................Talladega 16 .................................................Houston 17..................................................Barbour 18........................................................Pike 19 .................................................Calhoun 20.....................................................Butler 21 ................................................Marengo 22 ..................................................Monroe 23.....................................................Coosa 23 ...................................................Walker 25 .............................................Tuscaloosa 26 ................................................Lowndes 27 ...................................................Elmore 28 ..................................................Morgan 29.....................................................Henry 30 .............................................Tallapoosa 31...............................................Crenshaw 32 ..................................................Pickens 33 ...................................................Sumter 34...................................................Colbert

34............................................Washington 36 ..............................................Covington 36.................................................Madison 38...............................................Chambers 39 .................................................Autauga 40 .......................................................Dale 41.............................................Lauderdale 42...................................................Etowah 42 ...................................................Russell 44...................................................Geneva 45.................................................Choctaw 45 .................................................Franklin 47 .................................................Winston 48 .......................................................Clay 49....................................................Shelby 50 ..............................................Limestone 51.................................................Marshall 52 ...............................................Lawrence 53 .................................................Cullman 54 ....................................................Coffee 55 .................................................Baldwin 56...................................................Chilton 57 ...............................................Randolph 58 ...................................................Marion 59 ....................................................Blount 60 ...................................................Fayette 61 ..................................................Jackson 62.........................................................Lee 63 ....................................................Lamar 64 .................................................St. Clair 65 ...............................................Cherokee 66 ..................................................DeKalb 67 ................................................Cleburne

15

TABLE 1:Overall Chronic Disease BurdenRanking by Rank

OVERALL BURDENRANKING COUNTY

OVERALL BURDENRANKING COUNTY

Percent EstimatedBelow Estimated Estimated Adult Estimated Estimated Lung Colorectal Breast Overall

Percent Poverty Diabetes Hypertension Smoking Obesity CHD Cancer IR1 Cancer IR1 Cancer IR1 BurdenCounty Minority 2000 Prevalence Prevalence Prevalence Prevalence Prevalence 1996-2002 1996-2002 1996-2002 Ranking

Autauga 19.3% 10.9% 7.3% 30.1% 25.3% 23.3% 5.1% 74.0 53.7 143.7 39

Baldwin 12.9% 10.1% 7.7% 31.8% 24.2% 22.6% 6.0% 61.9 48.3 125.2 55

Barbour 48.7% 26.8% 9.0% 33.2% 24.1% 25.4% 4.9% 70.0 41.7 117.5 17

Bibb 23.3% 20.6% 9.3% 34.4% 24.1% 23.5% 6.1% 81.1 46.4 139.0 12

Blount 4.9% 11.7% 7.9% 32.3% 24.0% 22.5% 6.2% 75.4 41.6 104.6 59

Bullock 74.7% 33.5% 10.6% 35.3% 23.5% 27.4% 4.5% 57.3 52.7 98.8 14

Butler 41.6% 24.6% 9.6% 35.1% 23.0% 24.9% 5.7% 61.1 51.7 112.3 20

Calhoun 21.1% 16.1% 7.8% 31.7% 24.4% 23.3% 5.5% 92.7 56.6 133.2 19

Chambers 39.1% 17.0% 9.3% 34.4% 23.3% 24.7% 5.6% 65.3 44.1 108.2 38

Cherokee 7.2% 15.6% 7.6% 31.9% 24.3% 22.3% 6.1% 55.5 40.2 101.3 65

Chilton 13.3% 15.7% 7.2% 30.4% 25.0% 22.7% 5.5% 70.3 45.1 99.5 56

Choctaw 44.9% 24.5% 9.9% 35.3% 23.3% 25.3% 5.6% 44.5 32.5 71.1 45

Clarke 44.1% 22.6% 9.9% 35.3% 23.3% 25.3% 5.6% 64.1 67.6 162.5 3

Clay 17.4% 17.1% 8.1% 32.6% 24.0% 22.9% 6.0% 72.3 33.6 128.3 48

Cleburne 5.3% 13.9% 6.7% 29.3% 25.5% 21.8% 5.4% 65.4 45.5 93.0 67

Coffee 22.9% 14.7% 8.0% 32.1% 24.3% 23.5% 5.6% 64.0 37.3 119.6 54

Colbert 18.5% 14.0% 8.1% 32.4% 24.2% 23.1% 5.8% 76.5 53.9 119.6 34

Conecuh 44.6% 26.6% 9.8% 35.1% 23.0% 25.3% 5.7% 66.6 49.6 148.2 6

Coosa 36.1% 14.9% 8.9% 33.2% 24.1% 24.5% 5.4% 64.8 46.3 160.2 23

Covington 13.8% 18.4% 8.1% 33.0% 23.7% 22.6% 6.2% 77.1 49.1 117.6 36

Crenshaw 26.2% 22.1% 8.9% 34.0% 23.6% 23.7% 5.9% 70.8 38.8 128.0 31

Cullman 3.2% 13.0% 6.9% 30.4% 25.0% 21.9% 5.8% 78.0 50.0 121.4 53

Dale 25.6% 15.1% 7.6% 30.7% 24.7% 23.6% 5.2% 78.9 44.1 122.0 40

Dallas 64.4% 31.1% 10.6% 35.9% 22.6% 26.9% 5.1% 76.6 62.9 132.5 2

DeKalb 7.4% 15.4% 6.9% 30.1% 25.0% 22.2% 5.6% 58.1 41.1 101.1 66

Elmore 23.0% 10.2% 7.1% 29.8% 25.2% 23.4% 5.0% 83.4 64.3 151.1 27

Escambia 35.6% 20.9% 8.5% 32.6% 24.2% 24.4% 5.2% 80.2 47.5 141.6 11

Etowah 17.1% 15.7% 7.9% 32.1% 24.1% 22.9% 5.8% 77.4 47.4 112.2 42

Fayette 13.1% 17.3% 7.9% 32.5% 24.1% 22.7% 6.0% 54.4 40.6 98.5 60

Franklin 10.3% 18.9% 7.1% 30.7% 24.7% 22.3% 5.7% 83.0 48.8 111.3 45

Geneva 12.9% 19.6% 7.9% 32.4% 24.1% 22.6% 6.0% 71.4 47.1 115.9 44

Greene 80.9% 34.3% 12.4% 38.8% 22.2% 28.3% 5.1% 58.7 45.0 163.6 4

Hale 60.2% 26.9% 10.2% 35.0% 23.1% 26.4% 5.1% 80.0 65.6 165.6 1

Henry 34.3% 19.1% 9.3% 34.6% 23.4% 24.4% 5.8% 61.4 43.0 136.8 29

TABLE 2:Overall Chronic Disease BurdenRanking by County

16

Percent EstimatedBelow Estimated Estimated Adult Estimated Estimated Lung Colorectal Breast Overall

Percent Poverty Diabetes Hypertension Smoking Obesity CHD Cancer IR1 Cancer IR1 Cancer IR1 BurdenCounty Minority 2000 Prevalence Prevalence Prevalence Prevalence Prevalence 1996-2002 1996-2002 1996-2002 Ranking

Houston 26.9% 15.0% 8.1% 32.1% 24.1% 23.7% 5.5% 78.3 51.2 158.9 16

Jackson 8.1% 13.7% 7.2% 30.7% 24.9% 22.4% 5.7% 64.5 46.9 107.0 61

Jefferson 41.9% 14.8% 8.8% 32.8% 23.9% 24.9% 5.1% 75.9 60.4 157.9 7

Lamar 13.1% 16.1% 7.7% 31.8% 24.3% 22.6% 5.9% 57.7 33.7 108.2 63

Lauderdale 11.6% 14.4% 7.4% 31.1% 24.5% 22.5% 5.7% 69.0 54.9 144.7 41

Lawrence 22.2% 15.3% 7.6% 31.0% 24.9% 23.4% 5.3% 74.7 48.8 86.6 52

Lee 25.9% 21.8% 6.5% 27.3% 26.4% 23.4% 4.2% 47.9 35.3 106.4 62

Limestone 16.2% 12.3% 6.9% 29.6% 25.5% 23.0% 5.1% 69.7 54.5 123.2 50

Lowndes 74.1% 31.4% 11.0% 36.0% 22.7% 27.6% 4.8% 57.8 41.3 95.6 26

Macon 86.0% 32.8% 12.0% 37.6% 22.3% 28.7% 4.6% 45.5 53.3 103.3 13

Madison 27.9% 10.5% 7.6% 30.5% 24.7% 23.9% 5.1% 70.0 50.7 157.6 36

Marengo 52.7% 25.9% 10.2% 35.6% 23.0% 25.9% 5.4% 57.9 44.9 115.5 21

Marion 5.2% 15.6% 7.3% 31.3% 24.6% 22.1% 6.0% 57.8 48.0 119.4 58

Marshall 6.6% 14.7% 6.9% 30.2% 24.9% 22.0% 5.7% 81.1 51.4 120.0 51

Mobile 36.9% 18.5% 8.4% 31.9% 24.4% 24.5% 5.1% 88.3 60.5 148.5 5

Monroe 42.3% 21.3% 8.0% 31.7% 24.4% 23.9% 5.3% 68.1 50.3 130.8 22

Montgomery 51.2% 17.3% 8.7% 32.1% 23.8% 25.5% 4.7% 69.6 53.5 153.4 10

Morgan 14.9% 12.3% 7.2% 30.4% 25.0% 22.9% 5.4% 80.3 57.3 160.5 28

Perry 69.1% 35.4% 11.1% 36.8% 22.3% 27.0% 5.2% 62.5 54.8 98.0 9

Pickens 44.1% 24.9% 9.6% 34.8% 23.1% 25.1% 5.6% 74.4 29.9 93.4 32

Pike 39.2% 23.1% 8.3% 31.7% 24.2% 24.6% 5.0% 59.5 60.5 128.6 18

Randolph 23.6% 17.0% 8.3% 32.9% 23.9% 23.4% 5.8% 46.4 40.1 99.4 57

Russell 43.3% 19.9% 9.0% 33.2% 23.9% 25.1% 5.1% 63.7 39.4 83.6 42

St. Clair 10.0% 12.1% 6.9% 29.9% 25.4% 22.6% 5.4% 94.4 54.9 118.2 64

Shelby 10.2% 6.3% 6.4% 28.4% 26.1% 22.7% 5.0% 61.1 42.1 128.0 49

Sumter 74.1% 38.7% 11.1% 36.3% 22.6% 27.5% 4.7% 50.4 36.8 70.6 33

Talladega 33.0% 17.6% 8.3% 32.3% 24.2% 24.2% 5.3% 77.9 53.3 130.9 15

Tallapoosa 26.5% 16.6% 8.7% 33.7% 23.5% 23.7% 5.9% 59.2 52.2 135.3 30

Tuscaloosa 31.9% 17.0% 7.5% 30.1% 24.9% 24.0% 4.8% 72.6 51.8 152.3 25

Walker 7.8% 16.5% 7.3% 31.2% 24.6% 22.3% 5.8% 98.7 65.8 144.5 23

Washington 35.0% 18.5% 8.6% 32.6% 24.2% 24.4% 5.3% 68.6 45.9 113.1 34

Wilcox 72.5% 39.9% 11.0% 36.6% 22.4% 27.4% 5.0% 50.5 58.1 111.0 7

Winston 2.7% 17.1% 6.9% 30.5% 24.9% 22.0% 5.8% 88.9 46.3 135.7 47

1Rates per 100,000 persons in population

17

Figure 1: Cause of death was obtained fromvital events recorded by Alabama Center forHealth Statistics, using ICD-10 codes asfollows: heart disease, I00-I09, I11, I13,I20-I51; cancer, C00-C97; stroke, I60-I69;unintentional injuries, V01-X59, Y85-Y86;chronic lung disease, J40-J47; diabetes,E10-E14; pneumonia/influenza, J10-J18;kidney disease, N17-N19, N25-N29;Alzheimer’s disease, G30; other, all othercodes not specified above.

Figure 3: Awareness of hypertension wasasked each year from 1990 through 1993.Subsequently, the question was asked inalternate years. Absence of bar for datapoint (year) indicates no data available forthat year.

Figures 9, 12: Age-adjusted mortality ratesobtained from CDC Wonder site, usingICD-10 codes as follows: heart attack, I21-I22; stroke, I60-I69; respiratory disease,J40-J47; diabetes, E10-E14; hypertensivedisease, I10-I15.

Figure 10: Age-adjusted mortality ratesobtained from CDC Wonder site, ICD-10codes C00-C97.

Figures 11, 13: Age-adjusted mortality ratesobtained from CDC Wonder site, usingICD-10 codes as follows: lung cancer, C33-C34; breast cancer, C50; cervical cancer,C54-C55; prostate cacner, C61; colorectal,C18-C21.

Figure 14: Obesity defined as body massindex (BMI) greater than or equal to 30.0;overweight defined as BMI greater than25.0 but less than 30.0. BMI calculated asweight divided by height squared, usingself-reported height and weight.

Figures 23-27: Using data from the BRFSS1998-2002 estimated prevalence of diseasewas calculated for each of 12 race/sex/agegroups to account for differences in diseaseobserved across age, race, and gendergroups. Data were combined for year 1998-2002 and prevalence for disease or behaviorwas computed for black males, blackfemales, white males, and white femaleswithin the age groups 18-44, 45-64, and65+. These prevalence estimates whereapplied to population projections providedby the Centers for Business and Commerceand Economic Research (CBER) at theUniversity of Alabama, to generate preva-lence estimates for the disease/risk behaviorfor the next 20 years. The assumptionunderlying these calculations was that therate of disease would remain constant atthe estimated level throughout the 20 yearperiod to come.

Figure 28: All prevalence estimates are basedon combining multiple years of BRFSS datato generate age-sex-race specific prevalenceestimates. Prevalence rates were computedfor black males, black females, white males,and white females within the age groups18-44, 45-64, 65+. The years included inthis data set were 1998-2002, although not

APPENDIX:Definitionsand Methods

18

all of the prevalence data was available inevery year. These specific prevalence esti-mates where applied to each county usingidentical age/race/sex population break-downs to generate a county specific esti-mate. All of the counties were ranked byprevalence of disease/risk behavior, with thecounty having the highest prevalence givena ranking of 1. A similar scheme was usedwith cancer incidence data provided by theASCR. To determine the counties with thegreatest burden of chronic disease the rank-ings for each risk category in table 2 weresummed. The county with the lowest totalscore had the highest burden.

Prepared by:Martha M. Phillips, PhD, MPH, MBAAssistant Professor, Chronic DiseaseEpidemiologistUniversity of Alabama at Birmingham

Edited by:Sig HardenAlabama Department of Public Health

Sondra ReeseAlabama Department of Public Health

19

A L A B A M A

D E PA R T M E N T

O F P U B L I C

H E A LT H

Bureau ofHealth Promotionand Chronic Disease

The RSA Tower201 Monroe StreetMontgomery, Alabama36104

www.adph.org

Informationalmaterials inalternative formatswill be madeavailableupon request.

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